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									                                                        Colorectal Cancer Screening Program Referral
                                                        Fax to: 905-804-7944                Trillium Health Centre
                                                        Phone: 905-848-7695                 100 Queensway West Road
                                                                                            Mississauga, ON L5B 1B8

Patient Information:                                                      Provider Information:
First Name__________________________________                              Referring Physician: ____________________________
Last Name___________________________________                              Physician Billing #: _____________________________
Address: ____________________________________                             Phone #: ______________________________________

____________________________________________                              Date of Referral: _______________________________

Sex:    □ Male □ Female
D.O.B.: _____/Year _____/Month _____/Day                          □ After discussion with you, the patient is willing to go for direct
Phone (H)____________________________________                     □ Patient Incapable of Giving Her/His Own Informed Consent
Phone (W)____________________________________                     * NOTE: IF YOUR PATIENT DOES NOT SPEAK/READ ENGLISH, HE/SHE MUST
                                                                  BE ACCOMPANIED BY AN INTERPRETER AT THE TIME OF THE APPOINTMENT
Phone (C) ____________________________________
                                                                  Signature of referring physician: ___________________________
Health Card____________________ Version: ______

Indication for Colonoscopy (MUST CHECK ONE) – Patient must be ASYMPTOMATIC and meet ONE of the following:

□ Patient has one or more Positive FOBT (attach copy of result)
(Patient is being referred after a positive Fecal Occult Blood Test)                         PLEASE ATTACH SUPPORTING
□ Patient has a First Degree Relative with Colorectal Cancer                                 DOCUMENTS/RESULTS
( Mother, Father, Sibling, Child) has/had colorectal cancer
Age of relative at diagnosis ______ years, Patient age ______ years

Does your patient:                                                      Medications: (please list)    □ None
1.     Take Coumadin (Warfarin)?           □ Yes □ No                   ____________________________________________
2.     Take Plavix?                        □ Yes □ No                   ____________________________________________
3.     Take Aspirin?                       □ Yes □ No                   ____________________________________________

                                                                        Drug Allergies: □ None _____________________

Does your patient have: – CHECK ALL THAT APPLY
□ Abnormal Renal Function - Most recent serum creatinine level: _________           □ Previous Abdominal/Pelvic Surgery
□ Severe COPD/Emphysema or Other Severe Pulmonary Disease                           □ History of Adverse Reaction to Sedation/Anesthesia
□ Diabetes Mellitus on Medication - □ Oral Hypoglcemics □ Insulin                   □ Other:_____________________________________

Hospital Use Only:         □ Direct to colonoscopy             □ Consultation            Protocoling physician initials __________
                                                                                         Date ______________________________

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